Uncovering system errors using a rapid response team: cross-coverage caught in the crossfire.
Approach to Improving Safety
Setting of Care
Since adoption of the 2003 ACGME duty hour restrictions, targeted curricular and information technology initiatives have emerged to address safe handoffs in care. This study analyzed surgical rapid response team (RRT) calls to determine if greater discontinuity in care was a potentially contributing factor. Investigators found that impending respiratory failure and acute volume overload were the most common conditions prompting RRT activation. However, the more noteworthy findings were that RRT activations most frequently occurred during times of cross-coverage, resulted from team-based errors of omission, and were frequently preventable or potentially preventable events. A past AHRQ WebM&M commentary discussed a case of a failed signout process that contributed to a delay in treatment and diagnosis.